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Admission Conference

Remelou G. Alfelor
GENERAL DATA
G.F.
51 years old
Female
Married
Filipino
Roman Catholic
CHIEF COMPLAINT
RIGHT BREAST MASS
HISTORY OF PRESENT ILLNESS
3 months PTA
Palpated right breast mass
Movable, hard, non-painful when palpated, matchbox in
size (approximately 3x2x2cm)
Associated with nipple inversion
No nipple discharge, no discoloration of breast skin, no
fever, no erythema noted
HISTORY OF PRESENT ILLNESS
3 months PTA
Consult was done with private physician
Clinical impression: breast mass to consider malignancy
Core Needle Biopsy of right breast mass done
Invasive ductal carcinoma of right breast

Advised for surgery but patient failed to comply and lost to


follow up
HISTORY OF PRESENT ILLNESS
1 month PTA
Persistence of symptoms
Consult with current AP for second opinion
Mammogram was done which revealed
Advised repeat biopsy
HISTORY OF PRESENT ILLNESS
2 weeks PTA
Persistence of symptoms
Ultrasound guided core needle biopsy was done which
revealed invasive ductal carcinoma of the Right breast
Advised for surgery, hence admission
PAST MEDICAL HISTORY
(+) Hypertension, controlled
(-) Allergies
(-) Asthma
(-) Cancer
(-) Thyroid problems
(-) Cardiovascular Disease
(-) Diabetes Mellitus
FAMILY HISTORY
No hypertension
No asthma
No thyroid problems
No cancer
No diabetes mellitus
PERSONAL AND SOCIAL HISTORY
Non smoker
Non alcoholic
Denies illicit drug use
Married
OBGYN HISTORY
Menarche: 1 y/o
Interval: 28-30 days
Duration: 5 days
Amount: 1-2 pads per day
Symptoms: (-) dysmenorrhea

Menopause: 50 years old


G3P3(3003)
No history of oral contraceptive use
REVIEW OF SYSTEM
General: No weight loss, no loss of appetite, no fever, no chills
Skin: No clubbing of fingers, no jaundice
Head: No lightheadedness, no headache
Eyes: No blurring of vision
Ears: No hearing loss, no tinnitus
Nose: No epistaxis, no nasal congestion
Throat: No hoarseness, no dysphagia
REVIEW OF SYSTEM
Respiratory: No hemoptysis, no cough
Cardiovascular: No easy fatigability, no chest pain, no
orthopnea, no palpitations
Gastrointestinal: No diarrhea, no melena, no constipation, no
nausea
Genitourinary: No hematuria, no polyuria
Musculoskeletal: No edema, no muscle pain, no joint pain
Nervous System: No hallucinations, no insomnia, no vertigo, no
dizziness, no loss of consciousness
PHYSICAL EXAMINATION

GENERAL APPEARANCE Conscious, coherent, not in cardiorespiratory distress


Blood Pressure: 120/80mmHg
Heart Rate 80 bpm
VITAL SIGNS
Respiratory Rate 20 cpm
Temperature 36.2 C
Weight 64 kg
ANTHROPOMETRICS Height 1.54 m
BMI 27 (Overweight)
PHYSICAL EXAMINATION
SKIN Warm to touch with good skin turgor. No jaundice

HEENT Symmetric. Anicteric Sclerae. Pink palpebral


conjunctiva. Septum in midline. No naso-aural
discharge. No cervical lympahdenopathies.

CHEST & LUNGS Symmetric chest expansion. Clear breath sounds. No


retractions
Physical Examination

CARDIOVASCULAR Adynamic precordium. Normal rate with regular


rhythm. No murmurs noted

ABDOMEN Flat. Normoactive bowel sounds. Tympanitic


upon percussion. Non-tender. No masses felt.

EXTREMITIES No gross deformities. No edema noted. Full and


equal pulses.
Physical examination
Breast
2 surgical scars at the upper inner quadrant and right upper
outer quadrant each measuring approximately 2 cm
3 X 2 X 2 cm right breast mass, right upper outer quadrant
along periareolar area, hard, non- movable, tender.
No palpable axillary lymph nodes
Salient Features
51 years old
Palpable right breast mass
Biopsy result revealed invasive ductal carcinoma
Differential Diagnosis
Differentials To consider Rule Out

Fibroadenoma Palpable breast mass Age younger woman 15-


25 years old
No nipple inversion
Movable
Pagets Disease of the Palpable mass No nipple discharge
Breast Nipple inversion No ulceration
No discoloration breast skin
Mastitis Palpable mass No fever
Nipple inversion No erythema
No tenderness
Impression
Invasive Ductal Carcinoma, Right breast
Discussion
Anatomy of Breast
Arterial Supply
Internal Mammary Artery
Posterior Intercostal Arteries
Axillary Artery
Thoracoacromial Artery
Venous Drainage
Internal thoracic vein
Posterior intercostal veins
Tributaries of the axillary
vein
Batson's vertebral venous
plexus
Nerve Supply
Lateral Cutaneous branch of 3rd -6th intercostal
nerves
Anterior branches of Supraclavicular Nerve
Intercostobrachial Nerve
Lymphatic Drainage

1. Lateral Group Upper extremity


2. Anterior or Pectoral Group lateral
aspect of breast
3. Scapular Group lower posterior
neck, posterior trunk and posterior
shoulders
4. Central Group Axillary vein,
External mammary and scapular groups
of lymph nodes, breast
5. Apical Group
6. Interpectoral Group (Rotters
Nodes)
Lymphatic Drainage
Level I: Axillary Vein,
External Mammary and
scapular groups
Level II: Central and
Interpectoral Group
Level III: Subscapular
Group
Physiology
Estrogen : Ductal development
Progesterone:
Differentiation of epithelium
Lobular development
Prolactin
Lactogenesis (Late pregnancy and postpartum period)
Epithelial development
Oxytocin
Milk letdown
MASTECTOMY
TYPE OF MASTECTOMY ANATOMICAL PART REMOVED
TOTAL (SIMPLE)
All breast tissue, nipple areolar complex, skin
MASTECTOMY
SKIN SPARING All breast tissue, nipple areolar complex, scars
MASTECTOMY from any prior biopsy
EXTENDED SIMPLE All breast tissue, nipple areolar complex, skin.
MASTECTOMY Level I axillary lymph nodes
MODIFIED RADICAL All breast tissue, nipple areolar complex, skin.
MASTECTOMY (PATEY) Level I, II, III axillary lymph nodes
All breast tissue, nipple areolar complex, skin.
HALSTED RADICAL
Level I, II, III axillary lymph nodes, Pectoralis
MASTECTOMY
major, Pectoralis minor
Thank you and have a good day
Mammogram Results
Breast are heterogeneously dense which may obscure small masses.
High density speculated mass is seen in the right retroareolar region. There
is associated nipple inversion.
High density lymph node with no visible fatty hilum seen in the right
axillary region.
Benign calcifications are noted bilaterally
No suspicious microcalcifications or asymmetry evident
There is no skin thickening
Visualized left axillary region is unremarkable

Impression: BIRADS category 6